Treatment of psoriasis with intermittent short course cyclosporin (Neoral). A multicentre study

A 1 year, prospective multicentre study was performed to investigate the efficacy and safety of intermittent treatment with cyclosporin in psoriasis vulgaris. Subjects received cyclosporin (Neoral) 5 mg/kg per day until achieving 90% reduction in area affected, or for a maximum of 12 weeks. Those failing to demonstrate a satisfactory response were withdrawn. When further treatment was required, cyclosporin was recommenced. This cycle was repeated up to three times. Psoriasis activity was recorded using the area affected and sign scores for erythema, scaling and infiltration. Overall assessments of response and tolerability were recorded. Forty-one subjects, mean age 36, mean PASI 12.8, entered the first treatment period. Thirty-three received a second period of treatment and 16 a third. Eighteen failed to complete the study as planned: five were withdrawn due to adverse events, four due to treatment failure and nine due to protocol violations. At the end of each treatment period, significant improvements were seen in all efficacy parameters. Overall response was graded as 'considerable improvement' or 'minimal or no symptoms', by over 80% of subjects and investigators. Median intervals to relapse for subjects remaining in the study were 72 days (range 28-329) and 53 days (range 14-141) after periods 1 and 2, respectively. There were significant increases in mean serum creatinine and blood pressure during each treatment period. However, there were no significant differences in either parameter between baseline and the final follow-up visit. At the end of each treatment period, overall tolerability of the treatment was considered 'good' or 'very good' by over 80% of subjects and investigators.

Health promotion: an essential component of rehabilitation for persons with chronic disabling conditions

This qualitative study was undertaken to clarify an emerging explanatory model of health-promoting behaviors, and quality of life in individuals with chronic disabling conditions. Twenty individuals with multiple sclerosis shared their stories regarding health promotion, domains of quality of life, and factors that affected these domains. Health-promoting behaviors were viewed as essential to the process of rehabilitation and maintaining an acceptable quality of life. Important quality-of-life issues were related to domains other than function. Implications are that health promotion efforts need to be encouraged and supported in individuals with chronic disabling conditions.

A highly specific inhibitor of human p38 MAP kinase binds in the ATP pocket

The crystal structure of human p38 mitogen-activated protein (MAP) kinase in complex with a potent and highly specific pyridinyl-imidazole inhibitor has been determined at 2.0 A resolution. The structure of the kinase, which is in its unphosphorylated state, is similar to that of the closely-related ERK2. The inhibitor molecule is bound in the ATP pocket. A hydrogen bond is made between the pyridyl nitrogen of the inhibitor and the main chain amido nitrogen of residue 109, analogous to the interaction from the N1 atom of ATP. The crystal structure provides possible explanations for the specificity of this class of inhibitors. Other protein kinase inhibitors may achieve their specificity through a similar mechanism. The structure also reveals a possible second binding site for this inhibitor, with currently unknown function.

Alendronate in the treatment of Paget's disease of bone

We studied four treatment regimens of oral alendronate in 60 patients with active Paget's disease. Two groups received an oral daily dose of either 40 or 80 mg of alendronate for 3 months, followed by placebo for a further 3 months: the other two groups received treatment with 40 or 80 mg per day for 6 months. Activity of alkaline phosphatase and urinary hydroxyproline excretion were measured before, during, and after treatment, at intervals for a total follow-up of 1 year. A transiliac bone biopsy was performed in 24 patients before and after the treatment. An additional 16 patients had a third biopsy more than a year after stopping treatment. Alendronate induced a marked suppression in the urinary excretion of hydroxyproline within 2 weeks (p < 0.01) followed by a fall in serum activity of alkaline phosphatase at 1 month (p < 0.01) in all treatment groups. Nine months after the start of treatment patients treated with 80 mg for 6 months had a significantly lower mean alkaline phosphatase activity compared to the other treatment groups (p < 0.02), which persisted at 1 year (p < 0.05). Alkaline phosphatase decreased to within the laboratory reference range in all patients given 80 mg for 6 months. In contrast, alkaline phosphatase decreased to within the laboratory reference range in 73-83% of patients given 80 mg for 3 months and the 40 mg dose. Histomorphometric assessment showed a decrease in indices of bone turnover in the pagetic biopsies. None of the biopsies taken after treatment showed evidence of impaired mineralization of bone. Gastrointestinal side effects occurred in 25% of patients of whom two withdrew from treatment. We conclude that oral alendronate is an effective agent for the treatment of Paget's disease of bone.

The experience of fatigue and strategies of self-care among persons with multiple sclerosis

Fatigue is one of the most common and least understood symptoms of many chronic and disabling conditions. This qualitative study used a convenience sample (N = 13) of individuals with multiple sclerosis (MS). A semistructured interview guide was used to elicit a description of the experience of fatigue. Its perceived antecedents, and the self-care strategies used to manage it. Data were gathered during two 90 minute interviews. Five themes were identified that describe the experience of fatigue for persons with MS. Categories of self-care strategies included energy conservation, recharge efforts, enhancing resistance to fatigue, and temperature control. Further research is needed to explore the effects of specific interventions in the management of fatigue.

The effect of placing an aortic Wallstent across the renal artery origins in an animal model

OBJECTIVES

To assess the effect on renal blood flow and renal function of placing a Wallstent (Schneider (Europe) AG) across the renal artery origins in an animal model.

DESIGN

Laboratory animal study.

MATERIALS AND METHODS

Six Large White pigs had Wallstents placed across the origins of one or both renal arteries. Preoperative jugular venous blood samples were submitted for blood count and urea and electrolyte estimation. The pigs were recovered for 6 weeks. At sacrifice the renal arteries and their origins were examined by aortography and direct pressure measurements were recorded from the renal arteries and both the stented and unstented portions of the aorta. Renal venous blood samples were submitted for blood count, urea and electrolyte and renin estimation while renal arterial blood samples were submitted to examination for red blood cell fragmentation. The aorta with contained stent, renal arteries and kidneys were submitted for histological examination.

RESULTS

At sacrifice no renal arteries had occluded and the stent-covered origins appeared normal with no evidence of stenosis. This was confirmed histologically. There was no statistically significant difference between the arterial pressures measured in the stented and unstented portions of aorta and the renal arteries whether or not their origins had been covered by the stent. There was no statistically significant difference between the urea and electrolyte and renin levels of renal venous blood samples irrespective of whether or not the relevant kidney had a stent across its renal artery origin. Renal arterial blood samples showed no evidence of red blood cell fragmentation and histological examination of the kidneys showed no evidence of infarction or micro-emboli. Examination of the specimens by light and scanning electron microscopy demonstrated partial endothelialisation of the stents but the renal artery origins remained widely patent despite being crossed by at least one wire in all cases.

CONCLUSIONS

It may be necessary to place stents across renal artery origins during endovascular repair of abdominal aortic aneurysms. It would appear that covering renal artery origins with a Wallstent has no effect on renal perfusion pressure or function in this short-term animal model.

Crystallization and preliminary crystallographic analysis of recombinant human P38 MAP kinase

The recombinant human p38 MAP kinase has been expressed and purified from both Escherichia coli and SF9 cells, and has been crystallized in two forms by the hanging drop vapor diffusion method using PEG as precipitant. Both crystal forms belong to space group P2(1)2(1)2(1). The cell parameters for crystal form 1 are a = 65.2 A, b = 74.6 A and c = 78.1 A. Those for crystal form 2 are a = 58.3 A, b = 68.3 A and c = 87.9 A. Diffraction data to 2.0 A resolution have been collected on both forms.

Intra-arterial infusion of [125I]A beta 1-40 labels amyloid deposits in the aged primate brain in vivo

Alzheimer's disease is characterized by extracellular amyloid deposits in the brain at both vascular sites (cerebrovascular amyloid, CVA) and within the neuropil (plaques). In the present study we demonstrated that brain amyloid of aged non-human primates is efficiently detected by [125I]A beta in vitro, and assessed the detection of that amyloid in vivo by intravascular infusion of [125I]A beta. Aged squirrel monkeys (Saimiri sciureus) were anesthetized and infused intra-arterially with [125I]A beta, and sacrificed 2 h later. Analysis of the anterior frontal and temporal cortices by autoradiography demonstrated that [125I]A beta was deposited on CVA and that essentially every amyloid deposit which could be detected with thioflavin S or anti-A beta antibodies was also labeled by [125I]A beta. These experiments suggest that intravascular infusion of radiolabeled A beta can be used to detect and image amyloid deposits in the human AD brain.

Negative intraoral air pressures of deaf children with cochlear implants: physiology, phonology, and treatment

The primary purpose of this investigation was to examine deaf children's use of negative intraoral air pressures (-Po's) from a physiological and a phonological perspective, with the hope of gathering insight into the strategies these children use to produce speech. A secondary purpose was to compare the effectiveness of two methods of treating these deviant productions. Subjects were four profoundly deaf children, age 6:6-9:2, who used cochlear implants and had demonstrated persistent use of -Po's. Po's were collected during production of CV syllables with initial [p] and [b] and a variety of vowel contexts. Two of the children used -PO's more often before low than high vowels. We suggest that this vowel-based pattern may result when deaf children learn to lower their larynges in response to visible jaw lowering cues. Another child presented with a pattern of more frequent -Po's before front than back vowels, suggesting that she may have expanded her pharynx anteriorly as she attempted to achieve an anterior tongue placement. Two children also clearly used -Po's more frequently for voiced than voiceless stops, possibly resulting from a tendency to use the degree rather than the timing of vocal fold adduction to distinguish voiceless and voiced phonemes. Two of the children were enrolled in a single-subject multiple baseline study to compare the effectiveness of traditional articulation treatment and visual-feedback treatment. The child who was a far less proficient talker demonstrated rapid and sustained change, whereas the better talker demonstrated minimal change with treatment. This study provides evidence that (a) deaf children use speech production strategies quite unlike those of normally hearing children and (b) deviant speech behaviors of deaf children should be treated before they become part of functional phonological systems. This work highlights the need to consider the unique speech behaviors of deaf children, and their reliance on alternate feedback mechanisms, when developing assessment and treatment procedures.

Chronic endotoxemia and endothelium-dependent vasodilation in coronary arteries

Endotoxin acutely decreases the production of nitric oxide, leading to abnormal regulation of coronary vascular tone: however, the effects of chronic endotoxemia on vasomotion are unknown. We therefore tested the hypothesis that chronic, low-level endotoxemia inhibits endothelium-dependent vasodilation. Rabbits were continuously infused with a subclinical dose of Escherichia coli endotoxin (.6 microgram/24 h, intraperitoneal) or saline for 5 wk. Endotoxin at this concentration elicited no significant sustained pyretic or hemodynamic responses. Both endothelium-dependent and independent vasomotor responses were determined in coronary arteries (250-500 mu). Vasorelaxation in response to acetylcholine, but no adenosine diphosphate (ADP), was significantly enhanced in endotoxin-challenged animals (EC50 = 62.6 +/- 11.1 nM, control vs. 33.97 +/- 5.7 nM, endotoxin-challenged; p < .05). Vasoconstriction to PGF2 alpha, but not KCl, was significantly decreased in endotoxin-challenged animals. These results indicate that endothelium-dependent and independent vasomotor responses are altered during chronic endotoxemia and are due, in part, to alterations in signal-transduction mechanisms specific for certain types of receptors.

Neutrophil taurine in psoriasis

Neutrophil taurine was measured in 30 subjects presenting with chronic stable plaque-type psoriasis. The taurine concentration expressed per 5 x 10(6) cells was significantly lower (p < 0.002) in these subjects compared to neutrophil taurine measured in 20 control subjects. In view of increasing evidence proposing possible roles for taurine in maintaining normal neutrophil function coupled with previously observed anti-inflammatory effects of taurine in vitro, an assessment of possible roles of taurine in the aetiology of psoriasis is discussed.

Facilitative affiliation: nurse-client interactions that enhance healing

Facilitative affiliation is a new concept developed to capture the essence of effective nurse-client interactions, regardless of the client population or the practice setting. This concept has been synthesized within the theoretical framework of Modeling and Role-Modeling. Defining attributes have been identified as (a) presence, (b) assessment of needs based on the client's self-care knowledge and perceived resources, (c) creative individualized interventions, (d) selective normative disregard, (e) mutual trust, (f) nurturance, and (g) advocacy: Facilitative affiliation is defined as any nurse-client interaction in which the nurse assesses the client's needs based on that individual's self-care knowledge and perceived resources and creates individualized interventions based on those identified needs. The relationship is then characterized by availability, nurturance, and advocacy on the part of the nurse and a sense of mutual trust between the client and the nurse. Several client outcomes have been posited including that of enhanced healing.

Formaldehyde replaces glutaraldehyde in porcine bioprosthetic heart valves

BACKGROUND AND AIMS OF THE STUDY

In the production of porcine bioprostheses, the initial glutaraldehyde treatment is often followed by a short incubation in formaldehyde to ensure sterility of the valve. It is assumed that the glutaraldehyde cross links are stable and that the formaldehyde step does not alter the glutaraldehyde incorporated. The objective of this study was to determine whether the formaldehyde interacts with the tissue to cause changes in the glutaraldehyde composition.

MATERIALS AND METHODS

Two methods of tissue treatment were investigated: (i) fresh porcine leaflet tissue was treated with glutaraldehyde, followed by storage in formaldehyde, (ii) tissue processed in glutaraldehyde and transferred to formaldehyde for six hours was returned to glutaraldehyde for storage. The content of the two aldehydes was estimated by high performance liquid chromatography (HPLC), using an adaptation of the method developed by Hughes et al, which measures the acid labile Schiff bases formed between the collagen and the aldehyde.

RESULTS

The initial content of glutaraldehyde in the tissue declined from 63 +/- 10 nmol/mg dry weight to 21 +/- 4 nmol/mg dry weight when the leaflets were placed in formaldehyde for 24 hours. The initial uptake of formaldehyde was 800 +/- 144 nmol/mg dry weight after 24 hours and this declined to 370 +/- 33 nmol/mg dry weight over a 16 week period of storage in formaldehyde. By this stage, the level of glutaraldehyde had decreased to 2.4 +/- 0.2 nmol/mg dry weight. There was a sharp decline in the glutaraldehyde concentration from 89 +/- 6 nmol/mg dry weight to 14 +/- 1 nmol/mg dry weight when the tissue was placed in 4% formaldehyde solution for six hours. The formaldehyde uptake was 770 +/- 54 nmol/mg dry weight. After return to 0.625% glutaraldehyde solution the formaldehyde concentration declined whilst the glutaraldehyde concentration initially increased.

CONCLUSIONS

These results show that the formaldehyde reacts with the epsilon amino groups of lysine which had not reacted with glutaraldehyde, probably for steric reasons; and that formaldehyde replaces some glutaraldehyde in the tissue by a mass action effect. The tissue concentration of both aldehydes subsequently declined over the study period.

Nitric oxide synthase inhibition during experimental sepsis improves renal excretory function in the presence of chronically increased atrial natriuretic peptide

OBJECTIVE

To test whether renal excretory function decreases after nitric oxide synthase inhibition during experimental hyperdynamic sepsis.

DESIGN

Prospective, randomized, controlled animal trial.

SETTING

Research laboratory at a large university medical center.

SUBJECTS

Chronically instrumented Merino breed ewes (n = 18).

INTERVENTIONS

Continuous infusion of Escherichia coli endotoxin (10 ng/kg/min) for the experimental period of 32 hrs. One group received a bolus of the nitric oxide synthase inhibitor, N omega-nitro-L-arginine methyl ester (25 mg/kg), after 24 hrs, and the remaining sheep were given the carrier, sodium chloride 0.9%.

MEASUREMENTS AND MAIN RESULTS

The sheep developed a hyperdynamic cardiovascular response characterized by a decrease in systemic vascular resistance index (p < .05), and an increased cardiac index (p < .05) by 24 hrs. The sheep retained fluid, with creatinine clearance decreasing in the presence of chronically increased atrial natriuretic peptide. After the administration of N omega-nitro-L-arginine methyl ester, systemic vascular resistance index and cardiac index returned to baseline values, fluid balance normalized, and glomerular filtration rate increased (p < .05), while the control animals continued to retain fluid and their creatinine clearance continued to decrease. The concentrations of atrial natriuretic peptide did not differ significantly between groups after N omega-nitro-L-arginine methyl ester administration.

CONCLUSIONS

In this ovine model of experimental hyperdynamic sepsis, renal excretory function decreases in the presence of chronically increased concentrations of atrial natriuretic peptide. Administration of the nitric oxide synthase inhibitor, N omega-nitro-L-arginine methyl ester, reverses the vasodilatory state, thereby improving fluid balance and glomerular filtration.

Multiple keratoses and squamous carcinoma after PUVA treatment of vitiligo

PUVA is known to be carcinogenic when used in the treatment of psoriasis. To date skin cancer has not been demonstrated after PUVA treatment of vitiligo. We report a patient in whom multiple squamous cell carcinomata and keratoses developed in vitiligo areas after a prolonged course of PUVA. PUVA therapy of vitiligo induces repigmentation of affected skin in some patients. An increased frequency of cutaneous neoplasms in depigmented areas is a potential hazard, as in these sites the photoprotective effect of melanin is lacking.

The horizon-ratio relation as information for relative size in pictures

The horizon-ratio relation was found to be an effective source of information for relative size in pictures under some conditions: when the difference in image size of depicted "same real size" objects was not too great (Experiment 1), and when the horizon line was not too high or too low in the picture (Experiment 2). The latter finding seemed to be linked to the observers' identification of the horizontal line as the horizon (and not as the edge of a finite surface). In addition, individual patterns of response were remarkably systematic even in the absence of a horizon, or any other pictorial information, (Experiment 3). It is suggested that in this case observers imposed a horizon on the picture on which to base their relative size judgments, possibly based on the observer's own eye level or on the content of the picture. It is concluded that although the horizon-ratio relation provides the same kind of information as that available in the optic arrays from real scenes, pictorial information requires the satisfaction of additional constraints in order to be fully effective.

A new animal model for abdominal aortic aneurysms:initial results using a multiple-wire stent

OBJECTIVES

The effect of a plain 48-wire self-expanding flexible stent (Wallstent-Schneider (Europe) AG) on abdominal aortic aneurysms has been studied in a new animal model.

METHODS

Aneurysms were created by interposing fusiform segments of glutaraldehyde-tanned bovine internal jugular vein into the infrarenal aortas of 12 Large White pigs. The first six pigs were assessed after 6 weeks by ultrasonography and arteriography; they were then sacrificed for pathological examination. Endovascular placement of the stents, 2 weeks after aneurysm creation, was performed under arteriographic control in the next six pigs. These pigs were assessed by ultrasonography and arteriography 6 weeks after stenting; they were then sacrificed for pathological examination.

RESULTS

At 6 weeks the aneurysms in the first group were pulsatile with partial endothelialisation and no mural thrombus. Placement of the stent in the second group was accomplished easily. Stenting resulted in an immediate reduction in wall pulsatility of all aneurysms and thrombosis of the excluded aneurysm sac occurred in three cases. In the other three cases the pulse pressure in the sac was reduced. In all cases there was a significant reduction in maximum aneurysm diameter when measured 6 weeks after stenting.

CONCLUSIONS

A pulsatile, non-thrombogenic aortic aneurysm model approaching human dimensions has been successfully developed for the study of endoprostheses prior to their clinical use. Endovascular placement of a plain, multiple-wire Wallstent was associated with reductions in aneurysm pulsatility, pulse pressure within the sac and maximum aneurysm diameter over the study period. Stenting was associated with thrombosis of the excluded aneurysm sac in 50% of cases.